Treatment aspect of Vitiligo

Introduction:

Vitiligo denotes an acquired primary, usually progressive, melanocytopenia of unknown etiology, clinically manifested by circumscribed achromic maculus often associated with leukotrichia and histologically by degeneration and disappearance of melanocytes in the involved skin and not infrequently in the pigment epithelium of the eyes, leptomeninges and inner ear.  For treatment of vitiligo, skin colour and ability to tan (phototype), disease duration, and disease activity are important decision management items, as well as the patient psychological profile and ability of coping with the disease.

 

Treatment of vitiligo:

Before starting treatment, patient should be informed that :

1. Vitiligo is a chronic/relapsing disorder

2. Repigmentation is a slow process

3. Reactivation of the disease in different body regions or the reappearance of lesions in  treated ones may occur .

 

The different aspects of treatment are:

1. Topical

i) Topical corticosteroids

They are usually the first line in treatment of vitiligo in children and adult with recent onset. They have been used widely as topical and sometimes as intralesional therapy in vitiligo. They are not suitable for widespread lesions. Topical fluticasone and clobetasal dipropionate are commonly used.

When no results are seen after 3 months of potent topical corticosteroid, superpotent topical corticosteroids  can be tried. Skin atrophy is a common side effect.

 

ii) Topical calcineurin inhibitors

Tacrolimus ointment 0.1 and 0.03% and pimecrolimus cream 1% have an important role in treatment of vitiligo, particularly in areas where corticosteroids are contraindicated. They can be used in combination with UVB. Efficacy appears to be superior in sun-exposed areas. Side-effects like burning sensation , pruritus and erythema can occur.

 

iii) Vitamin D analogues

Calcipotriol and tacalcitol have been mainly purposed as supporting therapy during PUVA, NB – UVB, or excimer phototherapy (308 nm). They can be used in combination with topical steroids also.

Vitamin D analogues cause skin irritancy.

 

iv) PUVA and related treatment

It combines the use of psoralens with long length (320-400nm) UVA. Psoralens can be administered orally or topically.

In topical photochemotherapy a thin coat of 8- MOP cream (0.01 or 0.1 %) should be applied and UVA exposure done after  around 30 minutes. Initial UVA done is 0.12 – 0.25 j/Cm2 and increased weekly

According to patient’s skin phototype, and unless marked erythema appears. One or two weekly sessions are recommended. Repigmentation can be delayed until 6 months.

Topical 3% khellin in combination with natural sunlight can be safely used.

 

v) Basic Fibroblast growth factor

It is capable of multiplying melanocytes from hair follicles surrounding the affected skin and also acts as a chemotactic agent to direct the new melanocytes to the vitiligo patch.

 

vi) Placental extract preparation

Human placental extract is considered a biogeneous stimulation.

 

2)  Phototherapy

a)  PUVA therapy

In oral PUVA therapy, TMP at a dose of 0.6mg/kg is ingested with food 2 hours before sun exposure. Initially the exposure should be for 5 minutes and gradually increased until erythema begins. Twice a week treatment is given. If repigmentation is not seen after 20-30 treatments of 45 minutes exposure, dose of TMP is increased to 0.9 mg/kg body wt. If desired result is not seen after another 20-30 treatments, the drug is changed to 0.3 mg of 8-MOP along with artificial UVA. If this too fails then combination of TMP and 8 MOP may be tried.       Side effect like burn can occur. It should be avoided in patients less than 12 years of age, during pregnancy and lactation.

Ophthalmological check up including slit lamp examination should be done. Haematological, hepatic and renal function are to be expressed. Male genital areas have an increased susceptibility to skin cancer and should be shielded from UVA exposure.

 

b )  NBUVB therapy

It is currently the phototherapy of choice for vitiligo with lesser side effects. Generalized active vitiligo is preferentially treated with it. Narrow band fluorescent bulbs of Philips TL-01, each of 100 W with an emission spectrum of 311 nm is used.

Targeted phototherapy is used for selected treatment of lesional skin.                       Advantage of NBUVB over PUVA therapy are requirement of no oral medication, safe in pregnancy and childhood, and no post exposure eye protection requirement.

 

3) Systematic

a) Corticosteroids

Oral minipulse (OMP) i.e, intermittent administration of

Betamethasone / dexamethasone. It can arrest the progression of spreading disease but not useful to to repigment stable vitiligo. Optimal duration of OMP therapy to stop vitiligo progression is situated between 3 and 6 months.

Plasma cortisol and corticotrophin level was measured to detect hypothalamo-pituitary-adrenal axis suppression before and during the course of treatment. Side-effects like weight gain, insomnia, agitation, acne, menstrual disturbances and hypertichosis can occur.

 

b) Other immunosuppressive regimen

Cyclophosphamide at a dose of 50 mg twice a day could be used. Haemotological toxicity, loss of hearing , and nausea limits its use.

Azathioprine at a dose of 50 – 150 mg/ day can be used in association with PUVA therapy also.

Cyclosporine at a dose of 5mg/kg/day has been tried with no univocal response.

Levamisol in a dose of 150 mg on two consecutive days in a week has been tried in combination with topical corticosteroid.

 

c) Biologics

Immunomodulating biologics like tumor necrosis factor – alpha (Etanercept, Infliximab and Adalimumab) and LFA-1 (Efalizumab) have been tested with limited data available.

 

4) Surgical

Vitiligo should be stable before surgery is performed. It is most suitable for segmental unilateral vitiligo and focal vitiligo.

It can be

a) Methods based on direct transplantation of unprocessed tissue:

i) Suction blisters

Roof of induced fluid filled blisters are transferred to the prepared bed at the recipient site.

ii) Split thickness grafts

A dermo-epidermal tissue biopsy is directly transferred on prepared wound bed at the recipient site.

iii) Minigrafting

Small punch biopsies are transferred to the recipient site.

iv) Ultra thin grafting

An air driven high speed dermatome is used to harvest ultra thin shaves.

 

b) Methods based on transplantation of processed cells or tissue:

i) cultured epithelial sheets carrying melanocytes

ii) melanocyte suspension

This technique utilizes cell-culture expansion of melanocyte from a shape-biopsy

iii) Basal cell-layer suspension

Here, concentrated suspension of melanocytes and keratinocytes are used for transplantation. iv) Melanocytes and keratinocytes cultured  and delivered on defined membrane

 

UV light therapy and combination procedures may enhance repigmentation in treated patients.

 

5) Other Modalities

Cosmetic camouflaging has been recently recognised as being equally worth of consideration as a medical intervention when there are no satisfactory options. Self-tanners containing DHA are now available.

Highly pigmented creams containing titanium dioxide and iron oxide with 50% mineral oils and wax are waterproof and helpful in disfiguring vitiligo patches of exposed areas. Transfer resistant lip colour and lip tattoos are available now.

Camouflage can improve the quality of life.

Patient should also be explained about the good general health and a balanced nutritious diet enriched with adequate proteins, vitamin B-complex and E, and minerals like copper zinc and iron.

They need to be instructed regarding avoidance of physical, chemical and emotional trauma.

Avoidance of soaps and detergents containing phenolic  compounds, rubber goods and contact exposure to other chemical agents known to be detrimental to melanisation is advisable.

In patients with extensive and refractory vitiligo, depigmenting the remaining islands may be more cosmetically acceptable.

20% cream of monobenzyl ether of hydroquinone can be used once daily for 3-6 months.

Depigmentation has also been obtained by Q-switched ruby laser.

 

Conclusion:

There  is no ideal treatment and patient should be explained about the nature of the disease and its unpredictable course and prognosis. However, different modalities of treatment are available and proper selection is important. A successful treatment can change the life of an individual and his/her family.

 

References

1. Mauro Picardo, Alain Taieb (2014) Vitiligo Volume 2

2. R.G. Valia, Ameet R. Valia (2008) IADVL Textboo of Dermatology Volume 1

 

Dr. Yengkhom Jotshna Devi, MD